HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 139 VEST WAY 9/1/2023 Commonwealth of Massachusetts
City/Town of p1tip�3
R System Pumping Record S�Q
` Form 4
M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. - -(f�rornHOUSE: back side rear le right
A. Facility Information BUILDING: back side rear le right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your A dress
cursor-do not
use the return
key.
City/Town State Zip Code
2. System Owner:
ray
e Nam
Brun _
Address(if different from location)
MA
city/Town --- -- State I ?Cqqode
� l
Telephone Number
B. Pumping Record
1. Date of Pumping '='- - 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) [�Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — ---- - /--- ---- --
4. Effluent Tee Filter present? ❑ Yes �] No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumped:
6. System Pumped By:
Dave Tinley Mass 5821 Mass 1AA95E
Name Vehicle Li umber
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
GLSD
Signature of uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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